With four arms, a 3-D camera and tiny surgical implements on swiveling "wrists" wielded by a surgeon at a control panel, the robot could minimize incisions, pain, blood loss, complications and recovery time for patients.

Since then, the hospital's surgeons have performed 446 procedures, from prostate surgery to hysterectomies. Chief Medical Officer Dr. Drew Wilson said the results have been impressive.

Patients appreciate the smaller incisions and faster healing, he said. Doctors feel confident with the robot's precision and ergonomic control station.

Across the country, the popularity of the machine has skyrocketed, with an estimated 85 percent of all prostate surgeries now performed with the da Vinci system.

But high-technology comes at a cost, and a mounting number of studies are questioning whether the $2 million da Vinci is justified beyond its value as a razzle-dazzle marketing tool used to attract patients.

Perhaps more troubling, even some proponents of the robot question whether it is safe in the hands of doctors at small hospitals like Salinas Valley Memorial with too few procedures to build and maintain proficiency.

Dr. Jim Hu, chief of minimally invasive surgery in UCLA Medical School's urology department, has performed more than 1,500 da Vinci surgeries and conducted multiple studies involving the robot. He said it takes a surgeon between 250 and 700 procedures to master the tool.

Salinas Valley Memorial has granted da Vinci privileges to 10 surgeons since 2008. Together they have performed fewer then 450 surgeries.

Da Vinci creator Intuitive Surgical Inc. of Sunnyvale provides surgeons two days of training on the system. Surgeons at Salinas Valley can fly solo at the controls after as few as three proctored surgeries.

No da Vinci at CHOMP

To date, Community Hospital of the Monterey Peninsula has opted not to invest in the high-tech machine both for cost and safety reasons. Noting the da Vinci costs between $1 million and $2.5 million, spokeswoman Mary Barker said the hospital would not invest in the system unless there were local surgeons with expertise, enough volume to support continued expertise and clear-cut evidence that it's better. So far, it doesn't pass the test, she said.

Dr. Ezekiel Emanuel, an oncologist and former White House adviser, echoed the sentiments in a 2012 New York Times op-ed piece.

"This is a pseudo-innovation," he said, "a technology that increases costs without improving patients' health."

He cited a 2009 study that showed prostate surgery patients had shorter hospital stays and fewer surgical complications like blood loss, but later experienced more incontinence and erectile dysfunction.

Most of the published trials critical of the system do not question its safety, only its value. A study published Feb. 19 in the Journal of the American Medical Association found hysterectomies performed with the da Vinci robot cost about one-third more than other minimally invasive surgeries but had virtually the same outcomes.

While hospitals including Salinas Valley say they absorb the extra cost, experts say those costs are contributing to the rising price of health care.

"New medical technology and innovative devices can provide indispensable treatment options," Dr. Mark McClellan, former head of the U.S. Centers for Medicare and Medicaid Services, told Stanford Medicine Magazine. "Yet the costs of development and inappropriate use clearly contribute to the rising cost of health care."

In the most recent study, researchers at Columbia University reviewed the records of 264,758 women who had their uteruses removed at 441 U.S. hospitals between 2007 and 2010, a time when the use of the robot for the procedure surged from 0.5 percent to 22 percent.

A quarter of the women who had traditional laparoscopic surgeries required more than two days of recovery in the hospital, compared with 20 percent for those whose surgeries were da Vinci-assisted. The complication rate, however, was the same for both groups, 5 percent.

Meanwhile, the average total cost to the hospital for traditional laparoscopic surgery was $6,679, compared with $8,868 for the da Vinci. The da Vinci figure did not include the original price or the annual maintenance fee, which runs about $150,000.

According to a study reported in the Journal of Urology and Wall Street Journal, a hospital needs to do 520 da Vinci surgeries per year to bring its costs in line with traditional surgeries.

"Robotic surgery is clearly associated with higher costs, without any clear advantages," said Dr. Jason Wright, a gynecologic surgeon and one of the authors of the Columbia study.

Best for patient?

Salinas Valley Memorial, a public district hospital, paid just under $2 million for its da Vinci. In addition to the annual maintenance fees, each da Vinci procedure carries per-surgery costs of about $1,500 to $2,000, according to a report in the Wall Street Journal.

"We bear that additional cost, it's not passed on," Laurent said. "This is not about making more money off surgery. It's about what's best for the patient."

But there are no random controlled studies clearly showing da Vinci-assisted surgery is better for patients. And experts say advantages that are seen in terms of recovery and blood loss are likely attributable to the minimally invasive nature of surgery, which is available laparoscopically for many procedures at less cost.

On its website, Intuitive Surgical cites nearly 4,000 published articles and studies promoting the benefits of the robotic system. But a close look reveals many merely conclude the system is as safe as other surgical techniques.

One study found similar complication rates between traditional laparoscopic and da Vinci-assisted prostate surgeries, but said definitive conclusions were precluded by "the lack of randomized trials," the gold standard of medical research.

The only random controlled study of urologic surgeries the company cited concluded "the robotic approach (is) noninferior to the open approach."

Salinas Valley's Wilson objected that such controlled trials would have to be performed in a large facility and would require a patient to be randomly assigned to a surgical procedure rather than being given an option.

Laurent said patient preference was the driving force behind Salinas Valley's acquisition of the da Vinci.

Newer doctors train on it

Another reason more than 1,000 hospitals nationwide now have the robot is the expectation of new doctors who have been trained on it in medical school. One of them is Salinas urologist Dr. Andrea Chan, who joined the practice of doctors Leonard Renfer, Bricker Sweet and Dan Milanesa six months ago.

Chan said when she began looking for a community in which to start her practice, she only considered locations with the da Vinci platform. During her residency at the University of Texas Medical School, she assisted on more than 200 da Vinci surgeries and performed 60 herself under supervision.

She prefers the da Vinci, with its articulated wrists, over the straight laparoscopy instruments for some procedures, particularly those requiring a lot of suturing. The ergonomic control unit also allows doctors to sit comfortably during long surgeries, scales the surgeon's movements and filters out hand tremors that can accompany fatigue.

Chan said having the da Vinci at Salinas Valley offers patients an option they would otherwise have to travel to access.

The urologist said surgical outcomes are based more on the skill of the surgeon than the technique he or she uses.

"If you're precise, you're going to do a precise surgery whether its open or robotic," she said, adding that patients should ask their surgeon about their experience level and outcomes with the various techniques.

But UCLA's Hu and Community Hospital's Barker said it takes more than "good hands" to take the controls of the da Vinci, no matter how well-trained a surgeon is in open or laparoscopic surgery.

"This is a technology that, in the hands of people who use it every day, can result in faster recovery times," Barker said. "But for those who do not use it every day, which describes the vast majority of surgeons who are currently performing robotic surgery, the results can be much less impressive."

Would you feel more comfortable taking off with a pilot who flies a 747 several times a week or a couple of times a month, she asked.

Since Chan's arrival, another Salinas urologist, Dr. Aytac Apaydin, acquired da Vinci training and privileges that require as few as three proctored surgeries.

Laurent said Apaydin was certified on the system in 2009, but his privileges lapsed because he did fewer than 10 surgeries in two years. He performed four surgeries in 2009 and 2010. One of those was an eight-hour surgery that left a Salinas man with permanent nerve damage.

Apaydin did not respond to requests for comment.

Laurent said the hospital continually evaluates surgical outcomes but does not keep statistics comparing da Vinci surgeries to traditional laparoscopic or open surgery. Wilson said Salinas Valley did one comparison in the past and found no differences in complication rates.

Laurent and Myriam Curet, a proctor for Intuitive Surgical, said it is up to surgeons to tell their patients how experienced they are on the da Vinci. Curet, who is a bariatric and colorectal surgeon, said she tells her first 20 patients of any type of procedure her experience level and their options. None has turned down the da Vinci, she said.